When Hospice Care Falls Short

I am a palliative care physician and an ardent proponent for hospice care. At its best, hospice care is nearly miraculous in its ability to alleviate suffering and enable people to die in gentle and dignified ways. But the account that Ms. Brown gives of her father’s last days rings true. I’ve heard far too many similar stories to believe that it is an aberration. The appropriate term for what she describes is “bad care.”

People need to understand that there are no medical reasons for a patient in Ms. Brown’s father’s situation to suffer in agony. Intensive symptom management is effective and can be delivered in people’s homes.

Hospice programs care for the sickest patients. They must have nurses — and doctors — available at all hours of the day or night. Those clinicians must have immediate access to the same symptom-relieving medications that would be administered in an emergency department or hospital.

Hospice staff must be trained and regularly drilled on responding to pain crises, analogous to the way that hospital personnel are routinely recertified in cardiac life support. Nothing less will suffice.

IRA BYOCK, TORRANCE, CALIF.

The writer is a physician leader of the Institute for Human Caring, a quality improvement team within a large health system that owns hospice programs.

To the Editor:

It’s a shame that the in-home hospice patient and his daughter received such poor treatment when his death became imminent.

As a hospice nurse for Hospice of Palm Beach County, Fla., I helped our telephone triage team to become a reality and retired as a member of that team. Never again, to this present day, did a patient or a family member telephone and get an answering service.

When that phone was answered, it was always by a hospice nurse, and the patient’s needs were attended to right away, whether by the triage nurse getting a doctor’s order to increase the morphine the family member was giving the patient or whether an on-call nurse had to go to the home to assess the situation, which often meant admission to a hospice center or nurses around the clock at home.

Our patients died with pain under control and lessened anxiety, inasmuch as this was possible, and it almost always was.

For any of them to die in excruciating pain would have been the exception. I urge every hospice center to adopt the nurse telephone triage system. It is a godsend for the hospice patient and family.

PEGGY BUTLERWEST PALM BEACH, FLA.

To the Editor:

Karen Brown asks, “As the number of for-profit hospice providers grows, does that model provide too great an incentive to understaff nighttime and weekend shifts?”

You answered that question several years ago in “Differences in Care at For-Profit Hospices” (The New Old Age column, March 3, 2014), which reported that at for-profit hospices “patients are getting bounced as corporate bottom lines have come to matter more.”

While it may seem especially objectionable for the profit motive to influence end-of-life care, its destructive effects are felt throughout the health care enterprise, and it should have no role in virtually any health care setting.

A national improved Medicare for all would constitute one big step toward banishing this corrosive influence from health care.

ALAN MEYERS, BOSTON

The writer, a pediatrician, is a founding member of Physicians for a National Health Program.

After the paperwork had been done, a nurse arrived and handed me a box that contained several small bottles. “This is the morphine,” she explained. Pointing to another bottle, she said, “You give him this one if he has convulsions.”

Taken aback, I responded that I had no medical training and that I didn’t feel competent to administer these medications. “What do other people do?” I asked. She suggested that many people have family members or neighbors who are nurses and doctors and can help out. She would be back in a day or two.

I contacted a private agency and arranged for round-the-clock nurses at our expense. People should understand that in-home hospice means that for much of the time you are on your own.